Preventing incidents

The fifth step in the Incident Management System (IMS) cycle is to select and implement a solution.

You’ll identify the appropriate solutions while analysing and investigating an incident.

Key actions

Ensure your policies outline how to identify, implement and review solutions.
Ensure you understand your role in implementing actions.
Ensure your policies outline how to create and implement a remedial action plan.
Ensure your policies clearly define the analysis process.
Review progress regularly to measure your success and adjust actions when needed.
Engage affected parties to communicate each action's findings, progress, and outcomes.
When we've been notified, update us on your implemented solutions.

Deciding on appropriate actions

If an incident occurs, you should consider:

what actions could have prevented it or reduced its impact
if there is an ongoing risk to anyone
any measures to prevent or reduce the risk of it happening again.

Not all actions you identified during the analysis will necessarily be appropriate. It will depend on their relevance to and impact on your service.

Examples of remedial actions include:

providing mandatory staff training
changing your clinical governance framework
reviewing and updating your practices
developing new procedures which help staff to manage risks
updating your environment or equipment
promoting a safe culture of care
providing extra staff to help people with activities
seeking specialist assistance
implementing alternate strategies
updating care planning documents to address incident causes and impacts.

Disciplinary action

If an incident occurs, your organisation must consider and address human resources issues. This may include appropriate disciplinary action.

Implementing your remedial action plan

If an incident occurs, you must develop a remedial action plan with steps for everyone to follow. The plan should aim to:

improve the service or care you provide
inform new training
reduce future risks
prevent similar incidents from happening in the future.

These steps will help you create and implement a robust remedial action plan.

Define and break down actions logically and sequentially.
Set clear roles, responsibilities and expectations.
Assess the potential risks or barriers to any actions.
Set achievable goals and define your expected results.
Set expected timeframes for each action and the start and finish.
Identify what resources you need to support people.
Delegate tasks to relevant people.
Monitor and evaluate your success and make changes as required.
Record and communicate your findings and lessons learned.

You should ensure your workers understand their roles as part of these steps. Conducting regular check-ins with workers will help ensure continued success.

If an action in your plan is not successful, you should:

provide a timely update
decide if you need to make changes
record any changes in your IMS
communicate changes with the relevant parties.

Communicating your findings

If there is an incident, you must keep open communication with:

workers
board members
the public
those involved in the incident
people receiving aged care and their representatives.

Communication may include:

giving progress updates
discussing outcomes
advising relevant parties of any changes you make in response.

You must determine whether the incident has impacted the wellbeing of anyone receiving aged care. Talking to affected people and their representatives will ensure you understand their views.

Incidents will impact people differently, and some related emotional distress may not be obvious. This means it’s crucial to tailor your communication accordingly.

If the incident was reportable, you may have notified third parties, such as the NDIS Quality and Safeguards Commission. Please ensure you consult them on any solutions you implement.

You must also attach relevant supporting documents, such as your internal incident form.

Residential care incident example

George lives in the memory support unit. Having not seen George for an hour, personal care worker Kelly reported him as absent from care without explanation. A search of the facility did not locate him.

The facility contacted the police and notified George’s family. He was found at the local shops near the facility, confused and agitated but uninjured.

Due to the seriousness of the incident, management conducted an internal investigation. They also changed some processes in the memory support unit.

Your investigation

Your investigation finds that George has a history of wandering and was reported missing after a worker opened a facility door.

Your internal investigation identifies a range of actions. After considering the appropriate, you create the following 4-step remedial action plan.

Review George’s Behaviour Support Plan (BSP)

You discuss changes to George’s schedule and care routine with his representative and medical practitioners. The changes offer more structure and involvement in meaningful activities.

Discuss the incident and investigation and action with George’s family.

You speak to George’s sister about the incident and your proposed actions. This includes changes to his care plan for more regular visual checks by care workers. You email these changes to those affected.

Deliver relevant training

You deliver training on workers’ health and safety obligations and your relevant policies and procedures. You also roster workers to ensure everyone can attend.

Review organisational procedures to ensure there are no gaps.

Your review reveals that workers are not closing the door due to a lack of access cards. You respond by:

ordering spare access cards for workers to use during their shifts
setting up a report to outline how people use access cards and doors
updating door signs to emphasise the importance of secure exits.

Home services incident example

Hudson has a chronic medical condition that requires time-critical medication. His care plan states that workers must always have the medication with them so he can take it when needed.

One of Hudson’s care workers, Luke, regularly drives him to do his grocery shopping. One morning at the checkout, Hudson told Luke he was tired and pointed to a bench he would sit on to rest.

When Hudson went outside, he saw some friends sitting in the park and crossed the road to say hello. He then accepted a ride home and forgot about Luke.

When Luke left the shop, Hudson wasn’t where he said he would be.

Luke went back to Hudson’s house and waited outside for 30 minutes. With no way to contact Hudson, Luke called the next of kin and the home service provider.

The service spoke to the next of kin and decided to wait another 2 hours before calling the police. Hudson arrived home safely 2 hours after he went missing from the shops.

Your investigation

Your internal investigation identifies a range of actions. After considering the appropriate, you create the following 4-step remedial action plan.

Discuss expectations with Hudson and next of kin.

The service advises Hudson not to leave without telling his care worker. The two of them need to communicate during outings. This includes specifying the time to take medication, especially when it coincides with an outing.

Discuss the incident with Hudson and next of kin.

With Hudson’s consent, you arrange a meeting with him, his case manager and his daughter. You discuss how the incident happened and what actions may prevent it from happening again. You inform them that the incident was recorded in the IMS and reported to us, even though he got home safely.